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Breast cancer is a major public health issue in low-income and middle-income countries. In Mexico, incidence and
mortality of breast cancer have risen in the past few decades. Changes in health-care policies in Mexico have
incorporated programmes for access to early diagnosis and treatment of this disease. This Review outlines the status
of breast cancer in Mexico, regarding demographics, access to care, and strategies to improve clinical outcomes. We
identify factors that contribute to the existing disease burden, such as low mammography coverage, poor quality
control, limited access to diagnosis and treatment, and insucient physical and human resources for clinical care.
Introduction
Cancer accounted for 76 million deaths in 2008, nearly
13% of all deaths worldwide.1 The ratio of mortality to
incidence is substantially higher in low-income and
middle-income countries (6475%) than in high-income
countries (46%),2 which shows the great disparity in the
probability of survival within countries and across
socioeconomic groups.3
Breast cancer is the most common cancer in women
worldwide, with about 138 million diagnoses made
annually.1 460 000 deaths were reported in 2008, of which
269 000 (58%) were in low-income and middle-income
populations and countries, and 68 000 (15%) were in
people aged 1549 years in low-income countries.4,5
Global trends from 1980, to 2010, show that both
incidence and mortality have increased; however, rates
have risen fastest in low-income and middle-income
countries, thus worsening the burden of avoidable
disease, disability, and death in poor individuals.5 Breast
cancer needs to be detected and treated as early and as
best as possible.
Mexico has 31 states and one federal district
with substantial socioeconomic and ethnic dierences
between these regions. Generally, the northern and
central states are wealthy, whereas the southern states
are poor and include most indigenous populations.6,7
Socioeconomic dierences probably aect patterns of
breast-cancer incidence and mortality in the country.6
Similar to other middle-income countries, cancer
mortality has generally risen in Mexico, from 58 per
100 000 inhabitants in 1998, to 67 per 100 000 in 2008.
Since 2006, breast cancer has been the leading cause of
cancer mortality in Mexican women, accounting for 14%
of cancer-related deaths.8,9 GLOBOCANs prediction that
by 2030, 24 386 women will be diagnosed and 9778 (40%)
will die with breast cancer in Mexico, makes this disease
a substantial challenge for the health-care system.4
This Review provides a detailed overview of breast
cancer in Mexico, regarding demographics, access to
prevention, diagnosis, treatment and palliative care, and
strategies to improve clinical outcomes. Country and
regional initiatives are needed to address care of patients
with breast cancer worldwide.10,11 We aim to focus on
areas of weaknesses and future avenues to improve
www.thelancet.com/oncology Vol 13 August 2012
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Review
Screening
Routine mammography screening for selected women
reduces mortality from breast cancer by 723%.19 International recommendations for breast-cancer screening
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Breast cancer
Cervical cancer
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90
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95
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85
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Year
Figure: Age-adjusted mortality from breast and cervical cancer in Mexico, 19552008
Reproduced with permission from references 3 and 9.
Review
Clinical diagnosis
As in other low-income and middle-income countries,
breast cancer in Mexico is detected at a more advanced
stage than in high-income countries.49 A cross-sectional
study50 done in three public hospitals in Mexicos
Federal District reported that 90% of breast cancers
were diagnosed through a self-detected breast lump.
10% of patients had stage I disease, and 56% had locally
advanced or metastatic disease. In 2007, the National
Cancer Institute of Mexico (INCAN) issued a report of
patients covered by the Mexican health insurance, socalled Seguro Popular. 744 patients had newly diagnosed
breast cancer during that year: 8% presented with
stage I disease and more than 80% with locally advanced
or metastatic disease.51 This nding is in sharp contrast
to that in the USA,52 where 60% of newly diagnosed
breast cancers are mammographically detected at an
early stage.
Social and cultural barriers, ie, fear that the male
partner might leave at the rst sign of breast cancer,
poor awareness of the population and of primary healthcare providers, and decient mammographic screening
programmes, can lead to late diagnosis.9,53 A small study54
from a major public hospital in Mexico conrmed a
delay of 18 months between rst breast symptom and
rst primary-care consultation, followed by 66 months
from primary-care consultation to diagnosis, and
06 months from diagnosis to treatment, with an
average total delay of 10 months. Information is
restricted about the reasons for such delays. A study50
that included 40 women with reported delays of more
than 3 months showed that patients were responsible in
35% of cases and providers in 53%. A preliminary
report55 from INCAN showed that the most important
factors that account for dierences in appropriate
medical care of breast cancer are womens sociocultural
characteristics, especially poverty; social networks; social
support; accessibility to health services; and medical
errors in primary and secondary levels of care.
Mean age at diagnosis of breast cancer in Mexico is
50 years (SD 505),41,51,56 which is on average at least a
decade earlier than in European and North American
women.53 The age distribution of breast cancer in foreignborn and US-born Hispanic women is younger than that
of white American women and similar to that of patients
in Mexico.57 Furthermore, of Mexican patients with breast
cancer, 4050% are postmenopausal, 74% have had fewer
than two previous livebirths, and more than 70% have
never used oral contraception.41,58
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Accurate diagnosis and assessment of tumour biomarkers is crucial to guide breast-cancer investigation
and treatment recommendations. The most common
diagnostic methods in the morphological diagnosis of
breast lesions are ne-needle aspiration and core-needle
biopsy. Because each method has advantages and
disadvantages, centre resources and experience, and
clinical characteristics determine which one is chosen.59
In Mexico, information is scarce about quality of breastcancer specimens and diagnostic accuracy of biopsies.
Two studies from two national referral centres showed
that ne-needle aspiration biopsy of palpable lesions had
a positive predictive value of 97100% and a nondiagnostic rate of 3437% because of inadequate sampling or non-conclusive diagnosis.60,61 Although the
ndings for ne-needle aspiration are favourable and
similar to international performance results, they do not
indicate the status of the rest of the country.
In a biomarker study41 with 2074 patients, 57% had
hormone receptor-positive tumours, 20% had HER2positive tumours, and 23% had triple-negative disease.
The prevalence of triple-negative disease in this study
was higher than that reported in white patients (1013%)
and similar to that shown in several studies of Hispanic
patients in whom the proportion of hormone receptornegative tumours is between 17 and 30%, whereas the
distribution of HER2-positive tumours was uniform.62,63
Despite the clinical importance of methods for hormonereceptor and HER2 determination, their availability and
quality is not available for other centres that treat breast
cancer in Mexico. Other novel methods for genetic
proling, such as Mammaprint or OncotypeDx, are
generally not commonly available for Mexican patients
with breast cancer, and are mainly available at private
hospitals. INCAN reported results for 96 patients,
showing that physicians changed their treatment
recommendations in 31 (32%) of 96 cases on the basis of
genetic proling of tumours, with a decrease from 48%
to 34% in chemotherapy recommendation.64
Treatment
Financial protection and insurance
Mexico has three major types of public insurance: the
Mexican Institute of Social Security provides insurance
for private sector, salaried employees and their families,
and covers roughly 40% of the population; the Institute of
Security and Social Services for State Workers covers the
public sector, who make up roughly 7% of the population;
and the Seguro Popular, which began in 2004, and has
been steadily expanded, covers about 3540% of families
with a focus on the poorest individuals.51,65
The Seguro Popular covers breast-cancer diagnosis
and treatment through a network of 42 aliated hospitals by designating specic resources for each newly
diagnosed patient.51 Funding for breast-cancer treatment
for women who are not insured by the Social Security
Institution or the Institute of Security and Social Services
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Local-regional treatment
Both mastectomy and breast-conserving surgery with
radiation are standard treatments for primary breast
cancers.67 Since the US National Institutes of Health
consensus statement in 1990, breast-conserving surgery
is more common in the USA and mastectomies are
done in only 37% of cases.68 By contrast, mastectomy is
more common in low-income and middle-income than
in high-income countries, partly because of more
advanced disease at presentation, but also because of a
scarcity of available radiation therapy. A report from
INCAN showed an 85% mastectomy rate at their
institution.51 The risk of recurrence of ipsilateral breast
cancer indicates the quality of locoregional treatment
and is a predictor of systemic recurrence.67 INCAN is
the only establishment that has reported rates of positive
margins (dened as 3 mm) as low as 03% in treated
patients, either by breast-conserving surgery or
mastectomy,41 which is regarded as acceptable by
international standards.69
For the past 20 years up-front surgical dissection of
axillary lymph nodes has been replaced by sentinel
lymph-node biopsy because of the reduction in
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Systemic treatment
The estimated reduction in mortality from breast cancer
is 613% for adjuvant tamoxifen and 610% for adjuvant
chemotherapy. When combined with screening programmes, this reduction should result in a 2538%
overall decrease in breast-cancer mortality.19 Only a
few small phase 2 and retrospectives studies exist of
outcomes to systemic treatments. In the Mexican
Institute of Social Security, the main chemotherapy
schemes used are uourouracil, epirubicin, and
cyclophosphamide in 29% of patients, epirubicin plus
docetaxel in 18%, and cyclophosphamide, methotrexate,
and uorouracil in 15%, usually given for four to eight
cycles. Weekly trastuzumab is used for 8 months in 12%
of HER2-positive cases, although no information is
available about the proportional number of HER2positive patients in the studied population with breast
cancer.31 Patients treated through the Seguro Popular
receive an international standard of four cycles of
uouroracil, doxorubicin, and cyclophosphamide
chemotherapy followed by 12 doses of weekly paclitaxel.
Patients with HER2-positive tumours receive trasuzumab
for 1 year, and those with hormone receptor-positive
tumours receive tamoxifen for 5 years.41,58 Aromatase
inhibitorsthe rst choice of endocrine treatment
have rarely been used in Mexico, possibly because of
cost. However, the availability of generic forms of the
drug might increase their use. In a retrospective singlecentre study of neoadjuvant chemotherapy given to
204 patients in Mexico with anthracycline and taxanebased chemotherapy (42% for overexpressing HER2,
29% for triple-negative, and 9% for hormone receptorpositive tumours), pathological complete response was
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Review
Incidence*
Mortality*
74
292
0394
Mexico
272
101
0371
Brazil
423
123
0290
338
Argentina
74
201
0271
11
33
Uruguay
907
243
0267
28
European Union
771
166
0215
Peru
63
USA
76
47
0193
Uruguay
Canada
832
156
0187
400
2512
Mexico
35
Argentina
Brazil
Canada
Chile
Colombia
USA
66
Barbados
18
70
55
98
264
*Retrieved from PubMed (June 27, 2011) with medical subject heading breast
neoplasms and country. Retrieved from ClinicalTrials.gov (Jan 25, 2012) with
search term breast neoplasms and country.
Data are adapted from reference 4. *Age-standardised rates per 100 000 women.
Palliative care
The need for pain control and palliative care is crucial.
Similar to other developing countries, Latin-American
countries have limited access to palliative-care services.
In Mexico, the availability of palliative-care services has
been increasing since 1970, when the rst service was
established at INCAN. In 2007, an ocial norm for
palliative care was published, and in 2009, treatment
recommendations for breast cancer included guidelines
for pain control and palliative care based on international
guidelines.73
The availability of opiods is poor, which might be
explained by restrictive drug-prescription laws and
regulations in Mexico.74 Moreover, this eld has few
specialists, which further contributes to insucient
palliative care in Mexico.74
Research
To understand and reduce the public health burden from
breast cancer, clinical, epidemiological, health systems,
and translational research are necessary to identify and
address country-specic issues and to appropriately
incorporate advances in other countries. The World
Health Initiative reported that research is insucient in
Latin-American countries because of scarcity of funding
and available time for researchers, as an indicator of poor
support from governments.75
In November 2011, Mexico had 72 clinical trials of breast
cancer registered at ClinicalTrials.gov. Of these trials, 92%
were sponsored by industry and 8% were sponsored by
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Discussion
Increases in incidence and mortality related to cancer
in developing countries could be due to population
growth, ageing, lifestyle changes, and low health-care
expenditures, which are shown in screening strategies
and access to treatment.75 Latin-American countries
contribute to 10% of breast-cancer deaths worldwide.4
In Mexico, policy reforms and the addition of nancial
protection for several cancers through Seguro Popular,
including breast cancer in 2007, seem to be catalysing
change, at least for increased access and adherence to
treatment.
Improving trends in mortality for breast cancer in
Mexico since the late 1990s are not yet well explained.
They could partly be due to improvements in access to
screening, diagnosis, and treatment. However, this trend
started before changes in health-care policies and should
be analysed and compared with other trends in health
factors, such as obesity, diabetes, and other chronic
diseases, and changes in womens reproductive patterns
that are related to improvements in outcomes for breast
cancer. Despite these changes, breast cancer in Mexico is
still more lethal than it is in wealthier countries (table 2).
Eorts should focus on adapting treatment models that
are eective in other populations to the Mexican
population.
In low-income to middle-income countries, screening
programmes for breast cancer might start at a young
age because of the age of breast-cancer presentation.75
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Contributors
YC-G did the literature search and designed the gures and tables.
YC-G, CV-G, PERL, FK, DMF, and PEF planned the manuscript,
analysed the data, and, with AM, wrote the manuscript. FK analysed the
data.
Conicts of interest
FK is the wife of Julio Frenk, former Secretary of Health of Mexico;
participated in the design and research of Seguro Popular; and is a
co-investigator in a study funded by GlaxoSmithKline. All other authors
declare that they have no conicts of interest.
Acknowledgments
PEG, DMF, PERL, and YC-G thank the Avon Foundation New York.
We thank the National Council of Science and Technology (CONACYT)
for their nacial support to breast-cancer research (grant number 85055,
Sector Research Fund for Education), and Gustavo Nigenda and
Hector Arreola for reviewing the manuscript.
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